Duke University Medical Center and Lincoln Health Center (LHC) are collaborating to improve cancer control in a community health center that serves 30% of the Black population in Durham, North Carolina: 85 % of LHC's patients are black. African Americans experience disproportionate morbidity and mortality from cancer. In North Carolina, rates of mortality from breast, cervical and lung cancer are higher among African Americans compared to Whites. This probably reflects high rates of smoking and under-utilization of Pap tests and mammography. We are focusing on increasing three groups of services: Breast screening (clinical breast exam and mammography), Pap tests and smoking cessation counseling. Patient-directed (birthday packets with personalized birthday cards and reports and ethnically appropriate patient education materials and telephone counseling) interventions, physician-directed (physician education, reminders and health assessment forms) interventions and system-directed (a computerized prompting and reminder system) interventions will be used. The aims are to increase the proportion of age-eligible women who receive regular mammograms, Pap tests and clinical breast exams and the proportion of adult smokers who quit smoking. Shifts m readiness to change also are regarded as important. Chart audits, staff interviews and telephone surveys of patients will be conducted with a cohort of 1364 LHC patients to identify baseline proportions for the outcome variables. Patients then will be randomized to physician-directed interventions (PDI) alone, PDI plus low-intensity patient interventions (birthday packets and reminders) or PDI plus high-intensity patient interventions (birthday packets plus reminders plus telephone counseling). Finally, in year 4, a second chart-audit, staff interviews and follow-up interviews with the baseline cohort will be conducted to assess the impact of the interventions. Cost and organizational analyses will provide a clearer understanding of what does and does not work and at what cost. A final phase is planned for packaging and disseminating the interventions once the research period has ended. The research team is experienced in the development of patient-directed, physician-directed and system-directed interventions. The team includes family physicians and behavioral researchers, computer scientists, statisticians and an economist. The consultants have wide experience in designing and evaluating interventions for African Americans. The interventions have been proven effective in other settings and ready for a Phase IV test. A major improvement in the health of African Americans can be achieved by disseminating these strategies within the community health center. Our goal is to make a permanent change by integrating cancer control within the fabric of the health center.